Factors responsible for correct inpatient reimbursement
In inpatient auditing, ICD-10-CM diagnosis codes, ICD-10-PCS procedures codes, and much more are audited for correct inpatient reimbursement. The purpose of inpatient auditing is to ensure that the correct DRG was assigned.
The following factors play a role in making sure the correct inpatient reimbursement is received:
- Assignment of the principal diagnosis: If all of the correct diagnosis codes are assigned, but the incorrect one for the principal diagnosis is selected, the wrong MS-DRG will be assigned.
- Assignment of major complications or comorbidities (MCC): It is important to ensure that the coding guidelines are followed to capture all relevant diagnoses that make up major complications and comorbidities. Incorrect assignment of MCCs will lead into the wrong MS-DRG and result in incorrect reimbursement.
- Assignment of procedures codes: Assignment of ICD-10-PCS codes group an admission into an MS-DRG category. Coding a procedure with the wrong approach or root operation will cause a shift in the MS-DRG assignment. Coders should also be aware that some procedures routinely performed in surgical cases will cause an admission to be grouped into a higher MS-DRG.
- Coders need to read all of the AHA Coding Clinics that pertain to the diagnoses and procedure codes they assign.
- Assignment of Present on Admission (POA) indicators ? Coders need to review all diagnoses and assign Present on Admission indicators for all conditions that were present on admission. This helps to determine which diagnoses developed while the patient was hospitalized. Hospital acquired conditions (HACs) decrease the reimbursement that is payable to the hospital.
- Assignment of Discharge Status: It is critical the discharge status is assigned correctly. If a patient is discharged to a ?post acute? setting, the hospital will be paid a post acute DRG, which is a lower amount than the corresponding MS-DRG.
- Maintain knowledge of the OIG Work Plan ? The OIG issues a Work Plan every year. The Work Plan identifies DRGs that are highly prone to incorrect DRG assignment. Coders should understand how to correctly ensure these DRGs are not coded incorrectly.